Healthcare Provider Details

I. General information

NPI: 1154702256
Provider Name (Legal Business Name): JACKIE HORTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 4 BOX 854
COALGATE OK
74538-9624
US

IV. Provider business mailing address

RR 4 BOX 854
COALGATE OK
74538-9624
US

V. Phone/Fax

Practice location:
  • Phone: 580-399-5398
  • Fax: 580-927-2346
Mailing address:
  • Phone: 580-399-5398
  • Fax: 580-927-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5730
License Number StateOK

VIII. Authorized Official

Name: JACKIE HORTON
Title or Position: OWNER
Credential: LPC
Phone: 580-399-5398